Inspection visit

Health inspectionJanuary 16, 2020

MAPLE KNOLL VILLAGECMS #3653507 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, record reviews and staff interviews, the facility failed to ensure each resident was treated in a manner that promoted their individuality and dignity during dining. This affected two(#7 and #79) residents, who were dependent on the physical assistance of one staff to eat, of 36 residents located on the third floor of the facility. The facility census was 122. Findings include: Review of the medical record of Resident #7 revealed an admission date of 12/05/06, with diagnoses including Alzheimer's disease, dysphagia, volume depletion, and chronic kidney disease. Review of the resident's most recent quarterly minimum data set (MDS) assessment revealed the resident was identified by the facility as having short and long term memory problems, severely impaired cognitive skills, and being totally dependent on one staff person for eating/drinking. Resident #7 had contractures of both hands. The resident was located on the third floor secured unit. Review of the medical record of Resident #79 revealed an admission date of 01/12/16, with diagnoses including encephalopathy, dementia, restlessness and agitation, and irritable bowel syndrome. Review of the resident's most recent quarterly MDS assessment revealed the resident was identified by the facility as having short and long term memory problems, severely impaired cognitive skills, and being totally dependent on staff for eating/drinking. Resident #79 had contractures of both hands. The resident was located on the third floor secured unit. Observation on 01/14/20 at 8:33 A.M. of the residents on the third floor, secured unit, were observed having breakfast in the third floor unit dining room. There were four State Tested Nurse Aides (STNAs) and the Director of Nursing (DON) in the dining room at that time feeding residents who needed assistance to eat. All the residents had been served their breakfast at the time the observation started. There were two residents (#7 and #79) who were seated at tables with their breakfast trays in front of them and their food covered. There were nursing staff feeding other residents at the same tables as residents #7 and #79, sitting directly across from them. At 8:37 A.M., STNA #80 who had completed feeding another resident across the table from Resident #79, uncovered the food on the tray and began to feed Resident #79. At 8:44 A.M., one addition STNA #29 entered the dining room and uncovered Resident #7's food and began feeding her, 11 minutes after the observation began. Interview with the Director of Nursing (DON) on 01/15/20 at 5:30 P.M. regarding the observations made during the breakfast meal in the third floor dining room. The DON verified Residents #7 and #79 were served their food and not fed, while others around them were eating independently or being (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 365350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assisted as needed. She shared that she observed what as going on, and verbalized that STNA #29 was not readily available to assist with feeding as he was helping another resident who needed extensive assistance in the bathroom. The DON stated the expectations was that residents were to be fed at the time they were served. She stated that is how the meal period was arranged may need to be reviewed for example implementing two seating, or review utilization of staff during meals. The DON reported the problems was not related to lack of staff. Interview with STNA #80 on 0/1/16/20 at 10:27 A.M., regarding observations made during the breakfast meal in the third floor unit dining room on 01/15/20. STNA #80 stated that sometimes there were sufficient staff present to feed all the dependent residents when service, and sometimes not. STNA #80 shared that some STNAs may be assisting other residents with showers or other care needs, and then come to the dining room after the residents had already been served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on medical record review, observation, resident and staff interview, the facility failed to maintain a homelike environment. This affected one (#113) of 24 residents reviewed for environment. The census was 122. Findings include: Review of the medical record for Resident #113 revealed an admission date of 09/27/05 with a diagnosis of left lower extremity above the knee amputation. Review of the Minimum Data Set (MDS) assessment for Resident #113 dated 10/03/19 revealed resident was cognitively intact and required extensive assistance of two staff with transfers. Review of the care plan for Resident #113 dated 04/10/19 revealed resident had the potential for falls related to amputation. Interventions included transfer resident using a Hoyer lift. Observation of Resident #113's room on 01/13/20 at 9:30 A.M. and 10:22 A.M., revealed the Hoyer lift for the fourth floor was being stored in the resident's room. Resident #113 was in her wheelchair. Interview on 01/13/20 at 10:22 A.M. with Resident #113 verified the Hoyer lift for the fourth floor had been stored in her room since approximately 8:00 A.M. on 01/13/20. Resident #113 further stated she did not like the lift being stored in her room. Interview on 01/13/19 at 10:30 A.M. with Registered Nurse (RN) #66 confirmed the Hoyer lift was in resident's room and it was not in use. RN #66 further stated the Hoyer lift for the fourth floor should not be stored in a resident room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, mechanical lift manufacturer's recommendation review, facility policy review, facility investigation, witness statement review, and staff interview, the facility failed to provide two staff members when utilizing a mechanical lift for a resident transfer This resulted in actual harm when Resident #19 sustained a fall from the bed which resulted in a left distal midshaft hip fracture that required surgical intervention. This affected one (#19) of one residents reviewed for accidents. The facility census was 122. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/18/18 with a diagnoses of vascular dementia with behavioral disturbance, osteoporosis, spondylosis of lumbar -sacral region and spinal stenosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and with transfers. Review of care plan for falls initiated on 12/18/18 revealed the resident had the potential for harm/injury related to falls secondary to weakness, dementia with poor long- and short-term memory, impaired mobility, impaired cognition, prescribed antidepressant and antipsychotic, poor judgment and safety awareness. Interventions included the resident required the assistance of two staff with activities of daily living (ADLs). Review of the physical therapy discharge summary for Resident #19 dated 01/17/19 revealed resident received physical therapy services from 12/19/18 through 01/17/19. Further review of discharge summary revealed resident required maximum assistance of two staff with transfers, and staff should use the Sara lift (mechanical lift) when transferring resident. Review of physician orders for Resident #19 for January and February 2019 revealed staff should utilize Sara lift for all transfers and toileting with the assistance of two staff. Review of physician progress note for Resident #19 dated 01/10/19 revealed the resident required a stand-up lift for transfers and should have the assistance of two staff when standing. Further review of the note revealed the resident was a fall risk and required two-person assistance for transfers. Review of the nurse progress note for Resident #19 dated 02/14/19 revealed the resident was sent to the hospital via 911 due a fall which occurred on 02/14/19 at 6:15 A.M., and the resident had complained of leg pain immediately following the fall. Review of the facility fall investigation for Resident #19 dated 02/14/19 revealed the nurse found resident lying on the floor complaining of severe hip pain. Further review of the investigation revealed the State Tested Nursing Assistant (STNA) #177 reported the resident became combative with care and while attempting to secure the Sara lift pad around the resident, the resident began to slide out of bed, and STNA #177 lowered the resident to the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Review of the witness statement from STNA #177 dated 02/14/19 revealed the aide was by herself while attempting to transfer Resident #19 out of bed using the Sara lift. Further review of statement revealed Resident #19 became combative as the aide was positioning the lift pad around the resident and the resident began to slide out of bed. STNA #177 stated she then lowered Resident #19 to the floor. Residents Affected - Few Review of hospital records for Resident #19 dated 02/14/19 thru 02/16/19 revealed the resident was admitted on [DATE] due to a fall that occurred at the facility. Further review of the record revealed the resident sustained a fracture to her left distal midshaft femur which required surgical repair. Interview on 01/16/20 at 11:30 A.M. with the Director of Nursing (DON) confirmed STNA #177 had attempted to transfer Resident #19 using the [NAME] mechanical lift without the assistance of two staff on 02/14/19. The DON verified the resident sustained a hip fracture when she was lowered to the floor. Review of the Sara lift manufacturer's recommendations dated 04/20/16, revealed the Sara lift should be used in accordance with a full clinical assessment of the resident and his/her condition. Review of facility policy titled Lifting Machine, Using a Mechanical dated 09/23/19, revealed the resident center care may indicated the resident has been assessed to need two staff persons to use the sit-to- stand lift as per the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, facility policy review, resident and staff interviews, the facility failed to ensure tubing for oxygen and respiratory treatments was dated when opened and changed regularly. This affected two (#113 and #316) of two residents reviewed for respiratory care. The census was 122. Residents Affected - Few Findings include. 1. Review of the medical record for Resident #113 revealed an admission date of 09/27/05, with a diagnosis of left lower extremity above the knee amputation. Review of Minimum Data Set (MDS) Assessment for Resident #113 dated 10/03/19 revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living. Review of January 2020 physician orders for Resident #113 revealed an order for oxygen at two liters at bedtime and remove every morning. Observation of Resident #113 on 01/13/20 at 10:38 A.M., revealed the oxygen tubing was not dated. Interview on 01/13/20 at 10:38 A.M. with Resident #113 confirmed she was unsure when her oxygen tubing had last been changed. Interview on 01/13/20 at 10:45 A.M., with Registered Nurse (RN) #66 verified Resident #113's oxygen tubing was not dated, and she was unsure when it had been changed. RN #66 stated the oxygen tubing should be dated when opened and should be changed at least weekly. 2. Review of the medical record for Resident #316 revealed an admission date of 01/03/20 with a diagnosis of chronic kidney disease. Review of physician orders for Resident #316 revealed an order dated 01/05/20 for albuterol via hand held nebulizer three times daily. Observation on 01/16/20 at 8:17 A.M., of Resident #316 revealed the tubing to resident's hand-held nebulizer treatment was dated 01/05/20. Interview on 01/16/20 at 8:17 A.M., with Licensed Practical Nurse (LPN) #36 verified the tubing to Resident #316's hand nebulizer treatment was dated 01/05/20. LPN #36 further stated the tubing to the nebulizer treatments should be dated when opened and should be changed at least weekly. Review of facility policy titled Oxygen Connecting Tubing Cleaning/Change Procedure dated 09/13/16 revealed oxygen tubing should be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, medical record review, facility policy review, pharmacy online resource review and staff interviews, the facility failed to ensure expired medications were discarded and medications had an open date and expiration date. This had affected three (#79, #3 and #42) of 122 residents who received medications in the facility. The census was 122. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of 01/12/16 with a diagnosis of dementia. Review of the medical record for Resident #79 revealed an order dated 12/19/19 for acetaminophen liquid every eight hours routinely. Observation of medication storage room on third floor on 01/15/20 at 8:07 A.M. with Registered Nurse (RN) #66 revealed bottle of liquid acetaminophen with an expiration date of 12/2019. Interview on 01/15/20 at 8:09 A.M. with Registered Nurse (RN) #66 confirmed the medication storage room on the third floor contained a bottle of liquid acetaminophen with an expiration date of 12/2019. RN #66 confirmed the medication was expired and should have been discarded. 2. Review of the medical record for Resident # 3 revealed an admission date of 04/06/19 with a diagnosis of anorexia. Review of record for Resident #3 revealed an order dated 02/21/19 for one-half of a Vita-Day multi-vitamin tablet daily. Observation of the 300 Hall cart on 01/15/20 at 11:30 A.M., with Licensed Practical Nurse (LPN) #58 revealed the cart contained a bottle of Vita-Day multi-vitamin for Resident #3 which did not have a manufacturer's expiration date. The bottle had been dated as opened on 10/24/19. Interview on 01/15/20 at 11:35 A.M., with Licensed Practical Nurse (LPN) #58 confirmed the bottle of multivitamins for Resident #58 did not have a manufacturer's expiration date, and she could not confirm if it was expired or not. LPN #58 further stated expired medications should be discarded and not administered to residents. 3. Review of the medical record for Resident #42 revealed an admission date of 10/01/14 with a diagnosis of chronic kidney disease. Review of physician orders for Resident #42 revealed orders dated 11/01/16 for Refresh liquigel eye drops to both eyes twice daily and Refresh PM ointment to both eyes every night at bedtime. Observation of the 400 Hall cart on 01/15/20 at 7:42 A.M. with LPN #83 revealed the cart contained an undated opened bottle of Refresh Liquigel eye drops and undated opened tube of Refresh PM for Resident #42. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/15/20 at 7:50 A.M., with LPN #83 confirmed Refresh Liquigel and Refresh PM for Resident #42 were undated and opened. LPN #83 further stated ophthalmic preparations should be dated upon opening and discarded within 30 days. Review of the undated facility policy titled Drug Storage revealed expired medication should be removed from storage promptly and destroyed. Review of The International Pharmacopeia, Seventh Edition, dated 2017, (http://apps.who.int/phint/2017/index.html#d/b.6.2.1.3) revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interviews, review of the planned menus, and review of facility policy, the facility failed to prepared ground meat in accordance with the planned menu in order to meet the individual needs of residents with chewing/swallowing difficulties. This had the potential to affect 18 (#114, #69, #89, #15, #1, #86, #9, #60, #73, #68, #44, #43, #96, #19, #109, #50, #17 and #85) of 18 residents with a physician's orders for a soft/mechanically soft diet. The facility census was 122. Findings include: Observations of the meal preparation and service was observed in the central kitchen, and in the third floor serving, kitchen on beginning at 10:57 A.M. on 01/15/20. The planned menu for the lunchtime meal included a choice of soup, barbequed (BBQ) pulled pork, cole slaw or cantelope, and pudding or ice cream. Review of the production sheet for special diets, and the steam table set up sheet for the serving kitchens, revealed that pulled BBQ pork was to be of a ground consistency for residents on soft/mechanically soft diets. Observations on 01/15/20 at 11:42 A.M., the hot food arrived in the third floor serving kitchen in an enclosed hot cart from the central kitchen. At that time Dietary Staff (DS) #143 began setting up the steam table in the serving kitchen and the temperature of the food was taken at 11:50 A.M. There was no ground BBQ pork evident on the steam table for service. The pulled BBQ pork for regular diets included small chunks and strands of pork which would potentially not have been suitable for residents with chewing and/or swallowing difficulties. Observations at 12:04 P.M., revealed DS #143 began plating food for service in the third floor unit dining room and room trays. DS #142 was asked at that time if ground BBQ pork was to have been prepared for service. DS #142 and DS #143 affirmed there was no ground BBQ pork on the steam table, or in the hot cart delivered by the kitchen. DS #148 who was also assisting commented that the facility dietitian, Registered Dietitian (RD) #114 may have okayed the use of the pulled pork for the ground diets. Interview on 01/15/20 at 12:40 P.M. with DS #143 was asked if he was provided any additional information about the ground pork. He reported there was supposed to have been some prepared and sent up to the floor for the lunch time meal. He stated the central kitchen did prepare and send up ground consistency pork to the serving kitchen for service to residents on soft/mechanically soft diets after being questioned by the surveyor. Observation on 01/15/20 of Residents #73 and #68, both with orders for soft diets, were observed eating in the third floor dining room. The BBQ pork they were eating had been ground, and was obviously a different texture than the BBQ pork that was served to residents on regular diets in the same dining room. Interview on 01/15/20 at 3:11 P.M., with DS #142 regarding why no ground BBQ pork was prepared, until it was brought to the attention of dietary staff by the surveyor. DS #142 reported that DS #131, a sous chef, was responsible for preparing the ground pork for the lunchtime meal that day, that he missed the line specifying that 20 servings of ground pork were to be prepared. He affirmed that no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ground pork had been prepared in advance, but that BBQ pork was ground on discovery that none had been prepared and was served to residents on soft diets. Interview with Registered Dietitian (RD) #114 on 01/15/20 at 3:19 P.M., verified the BBQ pork served to regular diets during the lunchtime meal would have not been acceptable for residents with orders for a soft/mechanically soft diet. Review of the undated policy for diets revealed that residents are offered diets as ordered by the physician, and listed the diets. The diet described as soft/mechanically soft/dental soft specified that meat was to be ground to facilitate chewing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Knoll Village 11100 Springfield Pike Cincinnati, OH 45246 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on the medical record review and staff interviews, the facility failed to ensure a resident medical records contained documentation of resident incident resulting in injury. This affected one (#92) of 24 resident's medical records reviewed. The census was 122. Findings include: Review of medical record for Resident #92 revealed an admission date of 08/19/16 with a diagnosis of dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #92 dated 12/17/19 revealed resident was cognitively impaired and required extensive assist of one staff with activities of daily living (ADLs). Review of the nurse progress note for Resident #92 dated 12/14/19 at 4:18 P.M. documented by Licensed Practical Nurse (LPN) #38 revealed an order to apply pressure dressing to skin tear to resident's left arm, cleanse with normal saline, approximate skin, apply steri strips, monitor steri strips every shift until healed. Review of the medical record for Resident #92 revealed it was silent regarding an account of how resident sustained a skin tear to her left forearm on 12/14/19. Interview on 01/15/20 at 3:29 P.M. with LPN #38 confirmed the night shift nurse, LPN #8, reported Resident #92 had a sustained a skin tear to her left forearm during the night shift on 12/14/19. LPN #38 further confirmed she obtained a physician order for skin tear on 12/14/19 as it had started bleeding. Interview on 01/15/20 at 4:33 P.M. with LPN #8 confirmed the aide reported Resident #92 sustained a skin tear during care, and he applied a dressing to resident's arm. LPN #8 further confirmed he notified LPN #38 of Resident #92's skin tear at the change of shift report on 12/14/19, but he did not document the incident in the resident's medical record. Interview on 01/16/20 at 1:12 P.M. with the Director of Nursing (DON) confirmed Resident #92's medical record contained no documentation regarding an account of how resident sustained a skin tear to her left forearm on 12/14/19. The DON further confirmed incidents involving resident injury should be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365350 If continuation sheet Page 11 of 11

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0689SeriousS&S Gactual harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.

FAQ · About this visit

Common questions about this visit

What happened during the January 16, 2020 survey of MAPLE KNOLL VILLAGE?

This was a inspection survey of MAPLE KNOLL VILLAGE on January 16, 2020. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MAPLE KNOLL VILLAGE on January 16, 2020?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 16, 2020